Avir at Giddings

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for 1 of 5 residents (Resident #1) reviewed for quality of care. The facility failed to ensure that nursing staff responded to an unwitnessed fall for Resident #1, and when notified by staff member dismissed the fall as a behavior. The fall was not documented by staff, reported to the DON, physician, or resident representative (RP). This failure could place residents at risk for delays in care that could lead to worsening of a serious injury. Findings included: Record review of Resident #1's Facesheet dated 11/25/2025 reflected a [AGE] year-old, male admitted to the facility on [DATE]. Diagnoses included: Repeated falls, Impulse disorder, Cerebral Infarction, muscle weakness, unspecified lack of coordination, bipolar disorder, and chronic kidney disease requiring dialysis. Review of Resident #1's Quarterly MDS dated [DATE] reflected…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to provide pharmaceutical services including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all routine and emergency drugs and biologicals for 1 of 4 residents (Resident #1) reviewed for pharmacy services. The facility failed to ensure Resident #1's Tylenol-codeine 3 were acquired and administered according to physician's orders. These failures could place residents at risk for not receiving therapeutic dosages of their medications as ordered by the physician and a potential for decreased health status and decreased quality of life. Findings included: Review of Resident #1's face sheet reflected a [AGE] year-old female admitted on [DATE] with diagnoses of atherosclerotic heart disease (buildup of fats in the artery walls), unspecified dementia (symptoms that negatively affect memory, thinking, and social abilities), pain, other recurrent depressive disorders (repeated periods of significant sadness, loss of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 3 of 7 (Resident #6, #49, and #203) residents reviewed for accommodations. The facility failed to ensure that Residents #6, #49, and #203 had their call lights within reach while lying in bed. This failure could place residents at risk of injury, for not receiving timely care, and for not receiving nursing interventions. Findings included: Record review of Resident #6's face sheet, dated 02/26/2025, revealed an [AGE] year-old female, admitted on [DATE], with diagnoses that included cerebral infarction (a condition in which the blood flow to the brain is cut off causing brain damage), hemiplegia (the complete paralysis on one side of the body), and cognitive communication deficit (a condition that affects the ability to communicate effectively). Record review of Resident #6's quarterly MDS, dated [DATE],…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely for 2 of 3 shower rooms (shower rooms A and B), 2 of 24 resident rooms (Residents #18 and 35), and in 2 halls and 1 common area (halls 100 and 600 and the rotunda) reviewed for physical environment. 1. The facility failed to ensure shower rooms A and B were clean from 02/24/25 to 02/26/25. 2. The facility failed to ensure the rooms for Residents #18 and 35 were clean from 02/24/25 to 02/26/25. 3. The facility failed to ensure the 100 and 600 halls and the rotunda were free of unpleasant odors from 02/24/25 to 02/26/25. These failures placed residents at risk of discomfort and diminished quality of life. Findings included: 1. Observation on 02/24/25 at 10:03 AM revealed shower room A (entrance on the 100 hall) had a first aid bandage, hair, and a disposable glove on the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and record review, the facility failed to ensure pharmaceutical services were provided to meet the needs of each resident: specifically, expired or opened medical supplies were stored in 1 of 2 (100/200-hall Nurses' medication cart) medication carts. The facility failed to ensure expired or open supplies were removed from the 100/200-hall Nurses' medication cart that included one 5 x 9 Xeroform dressing that expired 01/2025, one sterile cotton tipped applicator that expired 08/01/2024, five 4 x 4 drain sponges that expired 12/05/2024, one 2 x 2 hydrogel saturated dressing that expired 11/15/2024, one 1 x 8 Xeroform dressing that expired 03/2024, three 6 x 7 Silicone Composite Dressings that expired 02/22/2025, and one opened package of rolled gauze bandage. These failures could place residents at risk of contamination causing illness or decreased effectiveness of medication. Findings included: Observation on 02/26/2025 at 11:50 AM of the 100/200 hall Nurses' medication cart with LVN E in attendance revealed one 5 x 9 Xeroform dressing that expired…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute food in accordance with professional standards for food service safety for one of one kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure fruit cobbler was covered, dated, or labeled after being in the refrigerator. 2. The facility failed to ensure CK K did not store her shoes on the kitchen utility cart in the kitchen. 3. The facility failed to ensure CK J properly used proper hand hygiene during food preparation. This failure could place residents who ate food from the kitchen at risk for foodborne illness. Findings included: 1. Observation on 02/24/2025 at 9:05 AM in the open front refrigerator located across from the steam table reflected a large pan of fruit cobbler not labeled, covered, or dated. Interview with the Dietary Manager on 02/24/2025 at 9:14 AM stated the fruit cobbler was made on Sunday (02/23/2025) to be served for lunch on 02/24/2025. She stated the fruit cobbler was expected to be covered, labeled, and dated. The Dietary Manager stated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interviews and record review, the facility failed to provide training on abuse, neglect, exploitation, and misappropriation of resident property, procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property, and dementia management and resident abuse prevention to their staff for 4 of 8 staff (RN A, CNA N, CNA O, and CNA P) reviewed for staff training requirements. The facility failed to provide RN A, CNA N, CNA O, and CNA P with orientation, as required by their abuse/neglect prevention policy and procedure prior to scheduling them to work with residents. This failure placed residents at risk of abuse and neglect. Findings included: Review of the personnel file for RN A reflected a hire date of 02/15/24. Her personnel file did not include documentation of the required orientation. Review of the personnel file for CNA N reflected a hire date of 06/24/24. His personnel file did not include documentation of the required orientation. Review of the personnel file for CNA O reflected a hire date of 01/17/23. Her personnel file…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 2 of 24 residents (Residents #35 and 104) reviewed for care plans. The facility failed to include Resident #35's behaviors of urinating in places other than the toilet in his care plan. The facility failed to include Resident #104's bilateral heel injuries in her care plan. These failures placed residents at risk of not having their care needs met. Findings included: Review of the undated face sheet for Resident #35 reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included dementia with behavioral disturbances and anxiety disorder. Review of the annual MDS for Resident #35 dated 12/19/24 reflected a BIMS score of 03, indicating severely impaired cognition. It reflected he required supervision or touching assistance with toileting hygiene. Review of the care plan for Resident #35 dated 01/23/25 reflected the following: [Resident #35]…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 2 of 8 residents (Residents #45 and 104) reviewed for quality of care. 1. The facility failed to follow up with treatment of a skin tear from a fall for Resident #45 after readmission from the hospital. 2. The facility failed to ensure Resident #104 had compression hose applied to both legs from 02/24/25 to 02/26/25 as ordered. These failures places residents at risk of not receiving necessary medical care, worsened swelling, infection, and hospitalization. Findings included: Record review of Resident #45's face sheet, dated 02/26/25, revealed a [AGE] year-old male, admitted on [DATE], with diagnoses that included cellulitis of left upper limb (an infection in the skin tissue), muscle weakness, unspecified lack of coordination, and other fracture of shaft of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility failed to ensure a functional emergency call light system in the bathroom for 1 of 5 (Resident # 38) residents reviewed for communication systems. The facility failed to ensure the emergency call light in the bathroom was functional for Resident #38. This failure could place the residents at risk of falls causing injury. Findings included: Record review of Resident #38's face sheet, dated 02/26/2025, revealed a [AGE] year-old female, admitted on [DATE], with diagnoses that included: Type 2 diabetes mellitus (a condition that affects how the body uses sugar as a fuel), muscle weakness, lack of coordination, chest pain, hypertension (high blood pressure), bipolar disorder (a chronic mood disorder that causes intense shifts in mood, energy levels and behavior), and atherosclerotic heart disease (condition that occurs when plaque builds up in the arteries, hardening them and limiting blood flow to the heart). Record review of Resident #38's quarterly MDS, dated [DATE], revealed a BIMS score of 15 which…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed, to provide an ongoing activities program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interest of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction for residents residing on secure unit, 100 hall, 500 hall and 600 hall. 1. The facility failed to provide activities on secure unit for the month of January 2025. 2. The facility failed to provide activities on 100, 500 and 600 halls 25 days out of 31 days for the month of January 2025, and 13 out of 20 days for the month of February 2025. This failure placed residents at risk for boredom, depression, increased behaviors, and diminished quality of life. Findings include: Review of the January 2025 Activity Calendar for the secure unit reflected it was the same calendar for residents not residing on the secure unit. Review of the secure unit group activity participation binder on 02/20/2025…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for two of eight residents (Resident # 1, and Resident #2) reviewed ADL care. 1. The facility failed to ensure Resident #1 and Resident #2 nails were cleaned, trimmed, and did not have any rough edges. This failure could place residents at risk for poor hygiene, dignity issues, and decreased quality of life. Findings included: 1. Review of Resident #1's face sheet, dated, 02/20/2025, reflected a [AGE] year-old male who was admitted on [DATE] and readmitted on [DATE]. Resident #1 had diagnoses which included type 2 diabetes without complications ( when your body can not use insulin properly or does not make enough insulin) unspecified lack of coordination (uncoordinated movement due to a muscle control problem that causes an inability to coordinate movements), and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure all residents were provided a nourishing, palatable, well-balanced diet that meets daily nutritional and special dietary needs for one (Resident #4) of five residents reviewed for needs and preferences. The facility failed to ensure Resident #4 received a diabetic diet as listed on his meal ticket and ordered by the physician. This failure placed residents at risk for altered nutritional status and decreased quality of life. Findings include: Record review of Resident #4's face sheet, dated 02/20/2024, reflected a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #4 had diagnoses which included type 2 diabetes without complications ( when your body can not use insulin properly or does not make enough insulin) unspecified lack of coordination (uncoordinated movement due to a muscle control problem that causes an inability to coordinate movements), unspecified dementia, unspecified…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain medical records in accordance with accepted professional standards and practices that are complete and accurate for 1 (Resident #3) of 5 residents reviewed for medical records. The facility failed to ensure nursing staff documented if the medical physician, nurse practitioner or family was contacted after Resident #3 fell on [DATE]. This failure placed residents at risk of not receiving the proper care and having medical records that are not current/accurate Findings included: Record review of Resident #3's face sheet, dated 02/20/2024, reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #3 had diagnoses which included unspecified lack of coordination ( uncoordinated movement is due to a muscle control problem that causes an inability to coordinate movements), unspecified fracture of right pubis, subsequent encounter for fracture with routine healing (part of the hip bone located on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 5 resident (Resident #1) reviewed for fall mats. The facility failed to ensure Resident #1 had a fall mat in place beside his bed per his care plan. This failure could place residents at risk of falls, injuries, pain, and hospitalization. Findings included: Record review of Resident #1's undated Face Sheet reflected he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of traumatic Subdural Hematoma (when blood leaks between the skull and the surface of the brain after a head injury) without loss of consciousness, Muscle weakness generalized, unspecified lack of coordination, and Alzheimer's Disease (progressive disease that destroys memory and other important mental functions). Record review of Resident #1's Comprehensive MDS dated [DATE] reflected he had a BIMS score of 8 indicating moderate cognitive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable and homelike environment for 7 of 7 residents (Residents #1- #7) and 4 of 6 halls (100, 200 secure unit, 500, and 600 halls) reviewed for physical environment. The facility failed to ensure the rooms for Residents #1- #7 and the 600-hallway area were clean and in good repair on 04/23/2024. This failure placed residents at risk of decreased quality of life. Findings included: Observation on 04/23/24 at 10:18 AM revealed a large light brown stain of pooled and dried liquid on the ceiling tiles of the 600 hall and a coating of black dust collecting in a large area around the air conditioner vent nearby. Review of the undated face sheet for Resident #1 reflected an [AGE] year-old male admitted to the facility on [DATE] with diagnoses including dementia, age-related cataract (clouding of the lens of the eye), and cognitive communication deficit (problems communicating caused by impaired cognition).…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure residents had the right to be free from abuse and neglect for 1 (Resident #1) of 5 residents reviewed for abuse and neglect in that: CNA A yelled (verbal abuse) at Resident #1, and refused to make up her bed so she could lie down on 04/12/23. The noncompliance was identified as past noncompliance (PNC). The non-compliance began on 4/12/23 and ended on 4/13/23. The facility corrected the noncompliance before the survey began. This failure (of verbal abuse) could place residents at risk of physical or emotional distress, and injury. Findings included: Review of the Face Sheet for Resident #1 reflected she was admitted on [DATE] with diagnoses of: Atrial Fibrillation, Alzheimer's disease, Hypothyroidism, Seizures, Chronic Obstructive Pulmonary Disease, major depressive disorder and Dementia with unspecified behavior disturbance. Review of the MDS significant change assessment for Resident #1 dated 11/13/23 reflected a BIMS score of 03…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 3 (Resident #78, Resident #54, and Resident #96) of 7 residents reviewed for safe, clean, sanitary, and comfortable environment in that: A. Resident #78's room had a section of the textured ceiling hanging down from water damage, had a window that would not properly seal allowing air in, and had a toilet with streaks and spots of a dried brown substance around the bowl and down the pedestal portion of the toilet. B. Resident #54's room toilet had a brownish yellow stain with debris in it that ran down the toilet from the bowl to the bottom of the pedestal. Resident #54's toilet was not properly secured to the floor, which allowed the base of the bowl to move some from side to side. C. Resident #96's room had two areas of paint missing from the wall to the side of his bed, which were visible to him and visitors. These failures could…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for sanitation. The facility failed to ensure all items were labeled, dated and discarded prior to its use-by date. The facility failed to ensure DA M washed her hands with warm water. The facility failed to ensure CK J manually washed dishes in water that was at least 120°F. The facility failed to ensure bread was not stored directly under an opened ceiling. The facility failed to ensure the food preparation sink in the dining room was clean and free of debris. These failures placed residents at risk of foodborne illness. Findings included: An observation of the kitchen's handwashing sink on 1/17/2024 at 9:20 a.m. revealed there was no warm or hot water . During an interview on 1/17/2024 at 9:21 a.m., CK J stated the pipe had been busted since yesterday (1/16/2024). CK K stated there was not hot water due to the broken pipe. CK J stated a plumber had come by the day prior (1/16/2024),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review the facility failed to ensure all drugs and biologicals were stored in under proper temperature controls in accordance with state and federal laws for one of one medication room. The facility failed to ensure the medications in the medication room were stored under proper temperature controls. This failure could place residents at increased risk of receiving medications that have been degraded by temperature changes and no longer provide a therapeutic effect resulting in adverse health consequences. Findings include: In an interview on 01/18/2024 at 10:01 AM LVN A stated the med room was hot. She stated they told her the air heater on the unit went in there. She stated she was in there the other day, and it did not take long for her to start sweating. LVN A stated the medication room had been really hot the last two days she worked 01/17/2024 and 01/18/2024. In an observation and interview on 01/18/2024 at 10:16 AM revealed the facility's one medication storage room, ) with door to the medication room open (room door is always closed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the right to receive written notice of a room change before the change was made for 1 of 2 residents (Resident #48) reviewed for resident rights. The facility failed to ensure Resident #48, received verbal or written notice prior to a room change. This failure could place residents at risk for being displaced without notice and/or reason in order to accommodate other individuals. Findings included: Review of Resident #48 Face sheet dated 01/19/2024 reflected a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses Cerebral Infarction (the pathologic process that results in an area of necrotic tissue in the brain. It is caused by disrupted blood supply (ischemia) and restricted oxygen supply (hypoxia).), Diabetes Mellitus Type 2 (A condition results from insufficient production of insulin, causing high blood sugar.) and Hypertension (High pressure in the arteries (vessels that carry blood from…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure all residents had the right to a safe, clean, comfortable and homelike environment for 1 of 8 (Resident #46) residents reviewed for homelike environment. The facility failed to ensure Resident #46's used bandage did not remain on his windowsill. This failure placed resident at risk of an unsafe, unclean, and uncomfortable environment. Findings included: A record review of Resident #46's face sheet dated 1/19/2024 reflected a [AGE] year-old male readmitted on [DATE] with diagnoses of congestive heart failure (end-stage heart disease), atrial fibrillation (irregular heartbeat), dysphagia (difficulty swallowing), cognitive communication deficit (difficulty communicating), hypertension (high blood pressure), unspecified dementia, and muscle weakness. A record review of Resident #46's quarterly MDS assessment dated [DATE] reflected a BIMS score of 8, which indicated moderately impaired cognition. A record review of Resident #46's care…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide, based on a comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities for group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, for 2 of 2 residents (Resident #50 and Resident #32), reviewed for activity preferences, in that: 1. The facility failed to provide individualized, person-centered activities to Resident #50. 2. The facility failed to provide individualized, person-centered activities to Resident #32. These failures could affect residents' psychosocial well-being and could lead to a diminished quality of life. The finding included: 1. A record review of Resident #50's face sheet dated 1/18/2024 reflected a [AGE] year-old female admitted on [DATE] with a diagnosis of Huntington's disease (inherited disease causing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow menus for 2 of 2 (Resident #7 and Resident #56) residents reviewed for menu accuracy. The facility failed to provide Resident #7 and Resident #56 pureed meat. The facility prepared pureed sandwich bread instead of cornbread for Resident #7 and Resident #56. These failures placed residents at risk of not receiving items on the menu and weight loss. Findings included: A record review of Resident #7's face sheet dated 1/19/2024 reflected an [AGE] year-old male admitted on [DATE] with diagnoses of unspecified dementia (cognitive impairment), muscle wasting and atrophy (muscle loss), muscle weakness, dysphagia (difficulty swallowing), nausea with vomiting, essential (primary) hypertension (high blood pressure), hyperlipidemia (high cholesterol), and vitamin B12 deficiency anemias. A record review of Resident #7's quarterly MDS assessment dated [DATE] reflected a BIMS score of 3, which indicated severely impaired cognition. This care plan…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to provide a safe, clean, comfortable, and homelike environment including receiving treatment and supports for daily living safely for 7 (Resident #'s 1, 2, 3, 4, 5, 6 ,7) of 9 residents' rooms observed for a safe, clean, comfortable, and homelike environment. The facility failed to ensure the A/C vents of Residents # 1, 2, 3, 4, 5, 6 and 7 were cleaned, maintained and free from dust and a black-like substance. The facility failed to ensure the windowsills of Residents # 3 and 5 were replaced appropriately. The facility failed to ensure that the tile on Resident #1's floor was replaced. The facility failed to ensure that the damaged wall on Resident #7's room was repaired and painted. These deficient practices could place residents at risk of infections and living in an uncomfortable environment leading to a decreased quality of life. Findings included: Review of Resident #1's face sheet dated 12/30/23 reflected a [AGE] year-old male who…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments for one of six residents (Resident #1) reviewed for medication storage. There was a Tylenol 650 mg on the floor under Resident #1's bed. This failure placed residents at risk of accidental ingestion of medication and not receiving therapeutic benefit of medications. Findings included: Review of the undated face sheet for Resident #1 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Alzheimer's disease, iron deficiency anemia, hypokalemia (low blood potassium), history of falling, gastroesophageal reflux disease (acid indigestion affecting the esophagus), anxiety disorder, chronic pain, cognitive communication deficit, hypertension (high blood pressure), muscle weakness, and schizophrenia (psychotic disorder causing hallucinations and paranoia). Review of the quarterly MDS for Resident #1 dated 05/11/23 reflected a BIMS score of 3, indicating severe…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.